The draft proposal was developed by a working group from the National Vaccine Advisory Committee (NVAC), outside experts who assist the US Department of Health and Human Services (HHS) with vaccine policy issues. In November 2010 they were asked to come up with strategies for reaching the 90% level for healthcare worker flu vaccination included in the Healthy People 2010 goals.

Some observers have questioned if the 90% mark is more of an "aspirational" goal than an attainable one. In past years, less than half of healthcare workers have received the seasonal flu vaccine. In December the CDC said it was cautiously optimistic this season, based on a November 2011 Internet panel survey of healthcare workers that found that 63% had been vaccinated at that point.

The number of hospitals adopting mandatory flu vaccination policies for healthcare workers is growing. The issue is a flashpoint with employee groups, however, who support vaccination and other efforts to control the spread of flu but believe workers should have the right to opt out for health, religious, or personal reasons.

Christine Nevin-Woods, DO, MPH, who cochairs the working group, presented the draft recommendations to the full NVAC board today. She is public health director of the Pueblo City-County Health Department in Colorado.

The process included a literature review of evidence-based strategies, several meetings with subject-matter experts, as well as feedback from a public Web conference and letters submitted by the public, which she said are still coming in.

She said the five-part recommendation reflects the opinion of the majority of the working group, with 24 of 27 of its members voting anonymously on each part. The report she presented included vote totals and fleshed-out majority and minority positions for each part.

The group proposed that healthcare facilities:

Establish comprehensive influenza infection control programs that include education on how to prevent flu transmission with tools such as hand hygiene, cough etiquette, free access to flu vaccines, and information on the benefits and misconceptions of flu vaccines Integrate flu vaccine programs into existing flu prevention and occupational health programs Continue efforts to standardize methods on how to measure healthcare worker vaccination rates Facilities that can't reach and maintain the 90% level without the first three steps should strongly consider requiring mandatory flu vaccination, the working group suggested.

Nevin-Woods said that recommendation didn't have full consensus, and its language was modified after rounds of deliberation. She told the group that the recommendation balances patient health and safety issues while maintaining flexibility for facilities based on their resources, patient safety issues, expertise, and labor concerns.

She said the group recognized concerns about the lack of scientific evidence on the impact of healthcare worker flu immunization on patient health and about flu vaccine efficacy.

The group's fifth recommendation called for new and better flu vaccines.

During the public comment part of the meeting, several healthcare workers, some representing employee groups such as National Nurses United and the California Nurses Association, objected to the fourth recommendation, the one that strongly suggests mandatory vaccination if facilities can't raise vaccination levels after completing the other three steps.

One nurse who addressed the group said the wording of the fourth recommendation was vague and could be interpreted by hospitals as a license to institute a mandatory flu vaccination requirement. Instead, she suggested that the recommendations mandate educational programs about flu vaccinations.

Rajini Raj, RN, with the Washington Hospital Center in Washington, D.C., said registered nurses care deeply about flu vaccination but added that flu vaccinations, due to limited efficacy and occasional problems with supply, can provide a false sense of protection for workers and their patients. She said the mistrust that can result from coercion and job threats "is not the way to protect public health."

On the other hand, Leonard Novick, executive director of the National Foundation for Infectious Diseases, spoke in favor of the recommendations, praising them as a "measured and tiered approach to the issue." He said the fourth recommendation is an important accountability feature that addresses a critical patient protection issue.

Deborah Wexler, MD, from the Immunization Action Coalition (IAC), based in St. Paul, said her group applauds facilities that adopt mandatory flu vaccination recommendations. The IAC's honor roll of such groups now includes 159 hospitals and healthcare systems.

She reminded NVAC members of the professional medical societies, such as the American Academy of Pediatrics and the American College of Physicians, that have supported mandatory flu vaccines for healthcare workers.

One member of the NVAC work group, Bill Borwegen from the Service Employees International Union, raised objections to the recommendations, asking if the group violated the Federal Advisory Committee Act, a set of rules for federal advisory groups, when a smaller subgroup worked on the final stages of the recommendations.

NVAC tabled the discussion for today to clarify the issues and will take up the topic again tomorrow during the second day of its public meeting. If the group adopts the working group's recommendations, the document will be forwarded to HHS Assistant Secretary Howard Koh, MD, MPH.